HONOLULU COMMUNITY COLLEGE
Name: __________________________________ Email Address: __________________________________
Banner ID: ______________________________ Phone: _________________________________________
Do you wish to be contacted? Yes No Anonymous
Please briefly describe your circumstance/situation
(Attach documentation or justification if applicable)
What remedy do you seek?
Student’s Signature: ______________________________ Date: _____________________________________
Referred to: _____________________________________ Date: _____________________________________
The Family Educational Rights and Privacy Act of 1974 forbids you to disclose any information about the student which is contained in this document, to any other
party either outside your organization or outside of the purpose for this disclosure without first obtaining the written consent of the student.